Arterial Injury in the

Upper Extremity
Evaluation, Strategies, and
Anticoagulation Management
Cory Lebowitz, DOa, Jonas L. Matzon, MDb,*

KEYWORDS
 Upper extremity trauma  Arterial injury  Angiography  Graft  Patency  Anticoagulation

KEY POINTS
 Upper extremity trauma with an associated arterial injury typically occurs via a blunt or penetrating
mechanism.
 Given the intricacy of the upper extremity arterial system, the diagnosis of an arterial injury can be
challenging and requires a high index of suspicion.
 Appropriate treatment of the arterial injury is dependent on the mechanism and location of the
injury.
 Although thrombosis is a common complication of arterial injuries, a standardized anticoagulation
regimen has yet to be established.

EPIDEMIOLOGY occlusion, arteriovenous fistula, and spasm.4,5

Vascular injuries to the extremities account for
fewer than 1% of all traumatic injuries, and upper
extremity arterial injuries comprise 30% to 40%
of all extremity arterial trauma.1,2 Typically, these
injuries are a result of a penetrating or a blunt force
mechanism. Although both mechanisms can
involve any surrounding tissue, blunt mechanisms
are associated with a higher morbidity and mortal-
ity due to the more generalized effect of the
trauma.2,3
With either mechanism, various types of arte-
rial injuries can occur, and these are grouped
into 5 types: intimal injury (ie, flaps, disruptions,
or subintimal/intramural hematomas), complete
wall defect with hemorrhage or pseudoaneur-
ysm, complete transection with hemorrhage or
Penetrating injuries typically cause wall defects.
In contrast, blunt trauma usually causes intimal
defects via a shearing contusion or crush injury.
As a result, focal intimal damage may lead to
the formation of an arterial dissection, throm-
bosis, or a pseudoaneurysm. Injury to a vessel
can also be secondary to a stress lesion, such
as a dissection or pseudoaneurysm caused by
compression of the vessel. Joint dislocation can
result in an occlusion or dissection injury. Spasm
can occur after either blunt or penetrating trauma
to an extremity and is more common in young
patients.5,6
Upper extremity arterial injuries have the poten-
tial to have a substantial impact on the overall
outcome for trauma patients. Given that these in-
juries most commonly affect men from 24 years

Disclosure Statement: None.

hand.theclinics.com

a
Department of Orthopedic Surgery, Rowan University School of Osteopathic Medicine, Stratford, NJ 080084,
USA; b Department of Orthopaedic Surgery, Thomas Jefferson University, Rothman Institute, 925 Chestnut
Street, Philadelphia, PA 19107, USA
* Corresponding author.
E-mail address: jonas.matzon@rothmaninstitute.com

Hand Clin 34 (2018) 85–95

https://doi.org/10.1016/j.hcl.2017.09.009
0749-0712/18/Ó 2017 Elsevier Inc. All rights reserved.
86 Lebowitz & Matzon
old to 38 years old, it is understandable how these
traumas present difficult medical and socioeco-
nomic problems.3,5,7 To properly manage these
injuries, it is vital to make an appropriate assess-
ment using all tools available.
EVALUATION
The arterial system of the upper extremity begins
with the subclavian artery and continues distally
as the axillary artery. In turn, this forms the
brachial artery, which eventually divides into the
radial and ulnar arteries in the forearm. Aside
from this typical path, a rich collateral circulation
exists (Fig. 1).8 With such an intricate vascular
network, the appropriate diagnosis of an arterial
injury in an upper extremity trauma patient can
be challenging. Specific algorithms can aid the
process by providing various subjective and
objective tools.
Fig. 1. An illustration demonstrating the arterial sys-
tem of the upper extremity. a, artery; aa, arteriae.
(From Daoutis N, Gerostathopoulos N, Bouchlis G,
et al. Results after repair of traumatic arterial damage
in the forearm. Microsurgery 1992;13(4):176; with
permission.)
As with any trauma, the evaluation of a patient
with an upper extremity injury begins with the
primary survey (ABCDEs according to the
Advanced Trauma Life Support protocol: Airway,
Breathing, Circulation, Disability and Exposure/
Environment).9 If signs of bleeding are recog-
nized, control by direct compression is advised.
In the rare situation where direct compression
is unable to provide adequate hemostasis, a
tourniquet can be used.9 Data collected from
Operation Enduring Freedom (Afghanistan) and
Operation Iraqi Freedom have demonstrated
that the appropriate application of a tourniquet
is effective in preventing loss of life and is safe,
with an overall complication of rate of less than
5%.9 If a patient’s vital signs are unstable, how-
ever, immediate resuscitation with blood transfu-
sion is indicated.9
Once a patient is hemodynamically stable, the
secondary survey is initiated with a detailed history
and physical examination focusing on the specific
upper extremity injury. Occasionally, the physical
examination can be misleading or unimpressive.
In fact, 5% to 15% of patients with a vascular
injury may present with a normal pulse examina-
tion.5 Therefore, careful attention must be paid
to any hard and/or soft signs of vascular trauma
(Table 1). Hard signs are an absolute indication
for vascular exploration, given that these patients
have an incidence of vascular injury greater than
90%.10,11 In contrast, patients with soft signs
have an incidence of vascular injury ranging from
3% to 25%.5
If there is a high suspicion of vascular injury in
the setting of soft signs, numerous noninvasive
diagnostic methods have been found helpful
(Fig. 2). One such diagnostic tool is the arterial
pressure index (API), which is the ratio of the
Table 1
Hard and soft signs of vascular injury in
orthopedic trauma
“Hard” Signs “Soft” Signs
Pulselessness History of bleeding in
Pallor transit
Paresthesia Proximity-related injury
Paralysis Neurologic findings
Pain from nerve adjacent
Rapidly expanding to a named artery
hematoma Hematoma over a
Massive bleeding named artery
Palpable thrill or
audible bruit
Data from Doody O, Given M, Lyon S. Extremities—indica-
tions and techniques for treatment of extremity vascular
injuries. Injury 2008;39(11):1295–303.
 Arterial Injury in the Upper Extremity 87

Extremity injury

Hard signs of Soft signs of vascular injury

vascular injury
or unstable
Unable to assess pulses due
ABI or ABI or to obesity or patient factors

Observe – serial exams

–
Watch for compartment
syndrome Imaging
Direct pressure or
tourniquet on bleeding

CT scan 64-slice CT or
angiogram (In OR or IR)

Spasm Intimal Active extravasation/

Thrombosis/Pseudoaneurysm/
AV Fistula

OR versus IR – Possible vascular

Observe surgery consult
serial exam for
Operating compartment Sx
room Serial exam for compartment Sx post
procedure

Fig. 2. Ivatury and colleagues9 formed algorithm that highlights the concepts published from the 2011 Western
Trauma Association’s masterful summary of “critical decision in trauma” on the subject of evaluation and man-
agement of peripheral vascular injury. IR, interventional radiology; OR, operating room; Sx, syndrome. (From
Ascher E, Haimovici H. Haimovici’s vascular surgery. Malden [MA]: Blackwell Pub; 2004; with permission.)

systolic pressure of the affected limb compared
with that of the unaffected contralateral limb. The
API is a reliable screening modality for significant
arterial obstruction with a negative predictive value
of 99%.9,10 An API greater than 0.90 is considered
normal and has a high specificity for excluding a
vascular injury. An API less than 0.90 warrants
further investigation.5
Doppler ultrasound is another noninvasive diag-
nostic modality that can aid in evaluating an upper
extremity arterial injury. It has an overall accuracy
of 98% in diagnosing vascular injury and has the
benefits of being inexpensive and noninvasive.9 It
is more specific than sensitive, however, it
has the limitations of being time consuming and
operator dependent.5,9 If uncertainty remains
after Doppler ultrasound, further evaluation is
necessary.12
Arteriography is considered the gold standard in
the diagnosis of extremity vascular injuries.9 Arte-
riography is an invasive and time-consuming
procedure, with well-recognized complications
that include puncture site injury, contrast
nephropathy, allergic reaction, and local vessel
injury. Digital subtraction angiography (DSA) is a
fluoroscopic contrast–based digital imaging mo-
dality used to assess vascular anatomy, whereas
CT angiography (CTA) is a radiographic-based
modality that reproduces the arterial vasculature
through 3-D volumetric analysis. CTA can rapidly
diagnose a vascular injury with similar diagnostic
sensitivity and specificity as DSA.6,13 Soto and
colleagues14 reported 95.1% sensitivity and
98.7% sensitivity with CTA in the detection of focal
arterial injuries of the proximal extremities. Unlike
CTA, however, DSA can be both diagnostic and
therapeutic.9 DSA is also superior to CTA in its
ability to diagnose a vascular dissection and to
accurately visualize the vessel lumen in the pres-
ence of foreign bodies, vascular calcification,
and partial thrombosis.6 In general, CTA is useful
in determining the injury location, nature, and
extent of vascular injury when not clearly evident
on physical examination3; however, DSA should
be used when CTA is inconclusive or if intervention
is needed.15
88 Lebowitz & Matzon
As described previously, caring for trauma pa-
tients with a possible upper extremity arterial injury
necessitates a thorough and efficient assessment.
Delayed or missed diagnoses can potentially lead
to failure of limb preservation. For example,
brachial artery injuries have a critical ischemia
time of approximately 4 hours.16 Furthermore,
depending on the injury location, and degree of
collateralization, forearm injuries have shown
poor outcomes with surgical management beyond
12 hours from injury.16 To prevent this, definitive
treatment is required after accurate diagnosis.
TREATMENT
Limb Salvage
Patients with upper extremity arterial injuries can
present in extremis. Therefore, initial treatment be-
gins with a goal systolic pressure of 80 mm Hg and
continues with the principle of life over limb.9 Once
a patient has been stabilized, attention is turned to
limb salvage. During the World War II era, the
prognosis after an arterial injury was extremely
poor. Of the 2471 patients who sustained arterial
trauma in the war, only 0.1% underwent success-
ful repair, whereas 68% required amputation.17
Fortunately, with advancements in medicine, the
success of limb salvage has improved.5 In some
patients with high-energy trauma, however, ampu-
tations may still be appropriate. The Mangled Ex-
tremity Severity Score (MESS) is an objective
criterion used to grade the severity of extremity in-
juries, which can be helpful in determining the risk
of amputation (Table 2).18 In a retrospective re-
view of 43 patients with a mangled extremity, Slau-
terbeck and colleagues19 found that all 34 patients
with a MESS less than 7 underwent a successful
limb salvage procedure, which substantiated pre-
vious findings that a MESS greater than or equal to
7 was the cutoff for amputation. In contrast, Pri-
chayudh and colleagues18 found that MESS was
a better tool for determining outcome than ampu-
tation. By basing their decision to amputate on
clinical signs and operative findings of irreversible
ischemia (ie, mottled, nonblanching skin; dark,
tense, noncontracting muscle), they avoided
amputation in 12 of 19 patients (63.2%) with a
MESS greater than or equal to 7. Yet, they
concurred that a MESS less than 7 remains a
good predictor for patients who do not require
amputation.18
For patients in whom limb salvage is deemed
appropriate, controversies exist over the ideal
sequence of surgical repair in combined orthope-
dic and vascular injuries.3 Advocates of initial or-
thopedic intervention argue that skeletal
stabilization is required to protect the vascular
Table 2
Mangled Extremity Severity Score
Factor Score
Skeletal/soft tissue injury
Low energy (stab, simple fracture, 1
low-energy gunshot wound)
Medium energy (open or multiple 2
fractures, dislocation)
High energy (close-range shotgun 3
or military gunshot wound, crush)
Very high energy (above conditions 4
plus contamination, avulsion)
Limb ischemia (score doubles for ischemia >6 h)
Pulse reduced but perfusion normal 1
Pulseless, paresthesias, decreased 2
capillary refill
Cool, paralyzed, insensate, 3
numbness
Shock
Systolic blood pressure >90 mm Hg 0
Transient hypotension 1
Persistent hypotension 2
Age (y)
<30 0
30–50 1
>50 2
From Slauterbeck JR, Britton C, Moneim MS, et al.
Mangled extremity severity score: an accurate guide to
treatment of the severely injured upper extremity. J
Orthop Trauma 1994;8(4):283; with permission.
repair and that open reduction internal fixation
may endanger the vascular repair. Initial vascular
intervention is supported, however, by the idea
of decreasing warm ischemia time. In general, it
is recommended that the orthopedic procedure
be performed first in patients without a pulseless
limb, absent capillary refill (ie, cold ischemia), or
a prolonged period of warm ischemia (ie, the pres-
ence of capillary refill). Furthermore, orthopedic
stabilization is also recommended to preclude
vascular intervention in the setting of very commi-
nuted and/or unstable fracture patterns.5
In contrast, vascular intervention is performed
first in patients with cold ischemia or prolonged
warm ischemia.5 In the setting of an ischemic ex-
tremity with an unstable fracture, vascular inter-
vention with a temporary shunt can be performed
prior to skeletal stabilization.10 The shunt allows
perfusion of the extremity during the primary or
provisional skeletal fixation. Shunts may also be
used temporarily to control hemorrhage, to pro-
long perfusion during transfer, or while awaiting

definitive vascular repair. These shunts can pro-
vide extremity perfusion similar to that of a
vascular repair for hours or even days.20
Vascular Repair
The technique of achieving definitive arterial perfu-
sion is dependent on the location, mechanism,
and severity of arterial damage. During wound
exploration, wide exposure is necessary to appro-
priately visualize the damaged vessel and to
adequately obtain proximal and distal control. Oc-
casionally, in cases of difficult exposure, such as
the axilla, proximal occlusion can be achieved
through the use of a Fogarty balloon catheter. After
complete visualization, both ends of the damaged
vessel are irrigated with heparinized saline to
decrease the risk of thrombosis.21 The damaged
vessel is then assessed for the appropriateness
of repair. For short segment injuries (<2 cm), pri-
mary repair is optimal if the arterial ends can be
mobilized to achieve a tension-free end-to-end
anastomosis. After freshening of damaged edges
and confirmation of arterial flow from both ends,
the repair is accomplished with nonabsorbable,
monofilament suture in an interrupted or contin-
uous fashion.4
Based on the extent of the vascular injury, pri-
mary repair is not always feasible. If resection to
healthy intima at both ends results in a long
segment gap (>2 cm), primary repair is typically
no longer a viable option.4 In this situation, an
autogenous vein graft, an autogenous artery graft,
or a synthetic conduit is needed to bridge the gap.
The ideal graft should be similar in diameter and
vessel wall thickness, readily available, easy to
harvest, and have minimal donor site morbidity.22
In evaluating the use of autogenous vein grafts
for arterial repair in injured extremities, Keen and
colleagues23 had an overall limb salvage rate of
97% with primary and secondary patency rates
of 99% and 98%, respectively.23,24 Other studies,
however, have reported outcomes with patency
ranging from 46% to 85%.24,25 Depending on the
location of the injury, various upper and lower ex-
tremity veins have been used as donors.23 Vein
grafts are typically easy to harvest and readily
accessible, but they can pose certain challenges
in the distal upper extremity. Specifically, veins
need to have their valves removed, or the grafts
need to be reversed to ensure patency. Valvuloto-
mies are challenging in smaller veins, and reversal
often complicates anastomosis, secondary to size
mismatch.22
Due to these difficulties with vein grafts and the
documented success of arterial grafts for cardiac
bypass procedures, some surgeons have started
Arterial Injury in the Upper Extremity 89
using arteries as upper extremity vascular grafts.22
The benefit of an arterial graft is the increased sim-
ilarity of the vessel wall anatomy and diameter be-
tween native vessel and graft, which can result in
improved flow characteristics.26 Commonly used
grafts include the deep inferior epigastric artery,
the lateral femoral circumflex artery, and the thor-
acodorsal artery.22 Masden and colleagues24
reviewed multiple studies that reported the use
of arterial grafts for distal upper extremity vascular
disease (acute and chronic), with patency up to
100%.24 Although most of these studies were
case series and surgical techniques susceptible
to selection bias, the use of arterial grafts for upper
extremity vascular injury seems a viable option.24
Another option for long segment defects is syn-
thetic grafts. Unfortunately, compared with autog-
enous grafts, synthetic grafts tend to have lower
patency rates and higher infection rates.27 There-
fore, synthetic grafts, like polytetrafluoroethylene,
are reserved for situations when autogenous graft
is not available.9
Although open surgical treatment remains the
standard of care for peripheral arterial injuries,
the continued advancement of radiologic imaging
and endovascular surgery has expanded the op-
tions in treating traumatic peripheral vascular in-
juries to include balloon occlusion, embolization,
and stent placement.6,28 Endovascular repair has
long been used for less urgent lesions, such as
arteriovenous fistula and pseudoaneurysm, and
these techniques are now finding their place in
emergent care.2 In some scenarios, endovascular
repair can be advantageous over open repair due
to its decreased operative time, minimal blood
loss, and lower frequency of iatrogenic injuries.
Specifically, endovascular repair is becoming
more common in treating subclavian and axillary
artery injury. These vessels are challenging to
explore, and patients with these injuries often pre-
sent with hemorrhagic shock and anatomic distor-
tion, which often complicates open repair.28 Worni
and colleagues29 found a lower in-hospital
morbidity and mortality for endovascular treat-
ment of peripheral arterial trauma compared with
open repair.29 Although the endovascular man-
agement of traumatic arterial injuries seems a
viable option, the studies of the technique are
limited in numbers and follow-up duration.28
Treatment by Location
Shoulder and proximal
Via its blunt mechanism, dislocation is a frequent
cause of vascular injury. Scapulothoracic dissoci-
ation is the most proximal upper extremity disloca-
tion and also one of the most rare.2 Patients with
90 Lebowitz & Matzon
scapulothoracic dissociation and an associated
arterial injury typically present with a chest wall he-
matoma, absent pulses, and loss of Doppler sig-
nals. Furthermore, these patients often have a
concomitant neurologic injury, with an association
reported as high as 91%.2 In contrast, patients
with an isolated subclavian artery injury have an
associated brachial plexus injury 18% to 33%
of the time.19 These combined injuries result in
significant short-term and long-term disability
compared with isolated brachial plexus injury.2
Depending on the severity of arterial injury and
the stability of the patient, subclavian arteries
can be repaired with any of the previous modal-
ities; however, in the setting of a mangled extrem-
ity, primary or secondary amputation remains a
consideration.19
Unlike scapulothoracic dissociations, uncompli-
cated shoulder dislocations result in arterial in-
juries less than 1% of the time.30 In this scenario,
the transection typically occurs from a tethering
mechanism that most commonly affects the third
part of the axially artery (Fig. 3).31 Unfortunately,
physical examination alone is frequently insuffi-
cient to rule out arterial disruption, because classic
signs of arterial injury may be absent in as many as
40% due to the abundant collateral circulation of
the shoulder.30 When there is concern for possible
arterial injury, the shoulder should be reduced
rapidly, without prolonging ischemia time.30
Then, the previously described work-up can be
initiated.
Fig. 3. Angiogram demonstrating an axillary artery
transection after a shoulder dislocation. (From
Ergünes K, Yazman S, Yetkin U, et al. Axillary artery
transection after shoulder dislocation. Ann Vasc Surg
2013;27(7):974.e8; with permission.)
When the axillary artery has been transected, a
primary end-to-end repair can often be performed
with ligation and division of side branches to
enable mobilization of the artery and a tension-
free anastomosis.2 In more complex tears, how-
ever, an interposition graft may be required.2 In
contrast, endovascular repair is a reasonable op-
tion when the axillary artery is disrupted secondary
to pseudoaneurysms, arteriovenous fistulas,
branch vessel injuries, intimal flaps, and/or focal
lacerations.31 When there has been minimal soft
tissue trauma, even ligation is an option with min-
imal consequence. When associated with exten-
sive soft tissue trauma, however, there is a high
likelihood of collateral disruption leading to a
decreased risk of limb survival.2 Furthermore, axil-
lary artery injuries can have an associated brachial
plexus injury secondary to the direct trauma that
occurs with a shoulder dislocation. Ergünes‚ and
colleagues31 reported a 90.4% rate of neurologic
injury when the axially artery was transected
from a shoulder dislocation.31 In contrast, the inci-
dence of a brachial plexus injury is 30% to 60%
when the axially artery is damaged from a pene-
trating injury.32
Elbow
Closed elbow injuries, such as pediatric supra-
condylar humerus fractures and uncomplicated
elbow dislocation, have the potential to disrupt
the brachial artery.30 In fact, 4% of patients with
pediatric supracondylar humerus fractures pre-
sent with a pale, pulseless hand.33 In this sce-
nario, skeletal stabilization is initially performed.
After closed reduction percutaneous pinning
(CRPP) of the fracture, 37% of patients have re-
turn of capillary refill and only 5% require vascular
exploration.33 Patients displaying signs of perfu-
sion (ie, pink hand) with pulses after CRPP can
be safely observed.21 In contrast, patients with
persistence of a poorly perfused, pulseless ex-
tremity after CRPP require immediate vascular
exploration (Fig. 4).34 There remains controversy,
however, whether to observe or explore patients
with a pulseless but perfused extremity after
CRPP.34
If the brachial artery is injured, it can be treated
with any of the previously discussed techniques.
End-to-end anastomosis is preferable if it can be
performed without tension or damage to major
collateral vessels, but higher-energy mechanisms
are more likely to require repair with a graft.2,12
Moreover, traumatic brachial artery injuries have
associated complications and injuries. Kim and
colleagues35 reported an approximately 20% inci-
dence of compartment syndrome requiring
fasciotomy in patients with a brachial artery
 Arterial Injury in the Upper Extremity 91

Pediatric supracondylar humeral fracture

Well perfused, with pulse Pulseless

Treat according to fracture type,

t Consider gentle traction and elbow flexion
not urgent
g from vascular
standpoint, but may be urgent
standpoint
for other reasons

Well perfused, pulseless Poorly perfused, pulseless

Somewhat urgent Emergent

Reduction not
Closed reduction acceptable Open reduction, identify artery

Acceptable reduction

Reevaluate vascular exam

Well perfused with pulse Well perfused, pulseless Poorly perfused, pulseless
Open vascular
exploration and
repair as needed,
ne
eeded,
consider
Inpatient observation
observ for Inpatient observation for 48 h compartment release
at least 12 h

Well perfused, no compartment syndrome Poorly perfused or developing

developi
compartment syndrome

Discharge from inpatient unit

Fig. 4. Flowchart for the management of an extremity with or without vascular compromise in the setting of a
pediatric supracondylar humerus fracture. (From Badkoobehi H, Choi PD, Bae DS, et al. Management of
the pulseless pediatric supracondylar humeral fracture. J Bone Joint Surg Am 2015;97(11):940; with
permission.)

injury.35 Furthermore, associated nerve injuries are Forearm/wrist

common with an approximate incidence of 25%,
and the median nerve is the most frequently
affected compared with the radial and ulnar
nerves.12 These associated injuries often limit the
function of the affected upper extremity even after
successful arterial repair and lead to a 36%
chance of long-term disability.12
Penetrating injuries to the radial and/or ulnar artery
in the forearm and wrist are typically the result of
lacerations by knife, glass, or machinery. Initially,
hemorrhage is controlled by means of
direct compression. Subsequently, a thorough
physical examination should focus on the nearby
muscles, tendons, and nerves, because these
92 Lebowitz & Matzon
are commonly injured.36,37 Although a patient typi-
cally presents with ischemia in the setting of an
injury to both the radial and ulnar arteries, ischemia
rarely results from a single-artery injury. This is true
even in the 20% of the population who have an
incomplete palmar arch, due to the intact collat-
erals between the radial and ulnar arteries.37 As
discussed previously, patients with hard signs
are brought to the operating room emergently.
Forearm arterial repairs in a well-perfused hand,
however, have showed no difference in functional
outcome when taken to the operating room emer-
gently (within 6 hours) or in a delayed manner.38
Surgical treatment of arterial injuries in the fore-
arm can be accomplished with repair or ligation.
When there is no distal perfusion, repair is the
treatment of choice. Gelberman and colleagues39
proposed that immediate repair of both vessels
be attempted when both the radial and ulnar ar-
teries are damaged and there is distal ischemia.39
In the situation where both arteries are injured yet
distal perfusion seems adequate, operative repair
of both vessels is still recommended to lessen
the chance that ischemic symptoms will
occur.17,39 In the setting of single-artery damage
(either radial or ulnar) with intact perfusion of the
hand, however, ligation versus repair is a topic of
debate.40 Due to the substantial collateral network
throughout the forearm and hand, ligation is
considered an acceptable option.3 First, it has
economic benefits because fewer resources are
required in comparison to repair.40 Furthermore,
Johnson37 found no instances of claudication
with ligation of a single vessel; however, hand
weakness (50%) and cold insensitivity (12%)
were noted in those with a concomitant nerve
injury.37 In contrast, Basseto and colleagues40 re-
ported greater loss of bone mass, muscular mass,
and strength in patients who had undergone arte-
rial ligation without an associated nerve damage;
hence, they advocated for surgical repair even in
single-vessel damage in the setting of perfusion.40
Although both surgical ligation and primary
repair can be reasonable choices after forearm
arterial injuries, neither option is without complica-
tion. Ligating a vessel or failure of repair can result
in acute-on-chronic ischemia. This scenario has
occurred after an acute traumatic event in patients
with a remote history of radial forearm flaps, where
the radial artery harvest is the source of chronic
disease. Due to adequate collateral blood flow,
the harvest may never show signs of ischemia until
an acute traumatic event.41 In primary repairs,
claudication, ischemia, and/or cold intolerance
are usually related with the patency of repair.42
Patency rates for an individual radial or ulnar artery
repair with use of microsurgical technique is
reported between 46%37 and 77%.43 Patency
can also be complicated by thrombosis, which oc-
curs from stasis and reduced flow, likely second-
ary to the high retrograde pressure in the distal
arterial stump from incompleteness of the
arches.39 For this reason, Gelberman and col-
leagues39 advocate for single-vessel repair
because some patients may have incomplete
arches.39 Early repairs within 36 hours, sharp lac-
erations (i,e not crush or avulsion injuries), and
radial repairs (when compared with ulnar) have
demonstrated higher patency rates.39 Due to the
potential of thrombosis, it is recommended that re-
pairs be assessed both clinically and diagnosti-
cally to correlate clinical symptomatology and
patency rates. This can be performed via Doppler
ultrasound and/or angiography.43
Hand
Acute arterial injuries to the hand and finger are
commonly the result of a penetrating mechanism
and are frequently work related.44 Arterial injuries
distal to the forearm are frequently accompanied
by an associated nerve, tendon, bone, and soft tis-
sue damage. Single digital artery injuries rarely
result in loss of distal perfusion, and, therefore,
they do not necessitate treatment in isolation.
When both digital arteries of a finger are injured,
however, the treatment algorithm is complex due
to the severity of associated injuries. Surgical op-
tions include amputation, revascularization,
replantation, flap coverage, skin graft coverage,
and others.45 Each technique has specific indica-
tions, but a review of the various options is beyond
the scope of this article.
ANTICOAGULATION MANAGEMENT
Besides adequate acute intervention, successful
treatment of upper extremity arterial injuries re-
quires appropriate postinjury management. Unlike
the standardized anticoagulation/antiaggregant
therapy for thrombus prophylaxis in chronic
vascular disease, the literature on the use of anti-
coagulation for the management of acute upper
extremity arterial injury is scarce. Although sur-
geons have documented anticoagulation proto-
cols based on their training and anecdotal
experience, few data exist to support one method
over another (Table 3).9,12,21,46–56
Although a standard protocol for anticoagula-
tion does not exist when managing upper extrem-
ity arterial injuries, Conrad and Adams57 made
recommendations for the use of antithrombotics
in managing free flaps and replants. They recom-
mended the use of aspirin for 2 weeks postopera-
tively, heparin as an intraoperative saline irrigant,
 Arterial Injury in the Upper Extremity 93

Table 3
Summary of recent anticoagulation use for upper extremity arterial injuries and their associated
treatment

Study Pathology Repair Anticoagulation

Mehlhoff Ulnar artery Venous graft Aspirin 325 mg tid
and Wood,47 thrombosis dipyridamole 3 wk
1991
Barral et al,48 Posttraumatic arterial Palmar bypass: radiopalmar, Ticlopidine 3 mo
1992 lesion, embolism, ulnarpalmar, distal radial subcutaneous heparin
aneurysm bypass, palmopalmar 15 d
Nehler et al,49 Distal to the wrist Arterial bypass Nothing
1992
Zimmerman Ulnar artery occlusion Ligation, arterial LMW dextran 72 h, then
et al,50 1994 reconstruction aspirin 325 mg for 6 mo
Ruch et al,51 Radial artery occlusion Vein graft LMW dextran for 72 h, then
2000 near the carpus aspirin 325 mg for 6 wk
Smith et al,52 Hypothenar hammer Autologous inferior Continuous infusion of
2004 syndrome epigastric artery diltiazem at 15 mg/h and
dextran for 24 h after
surgery followed by
diltiazem
Shalabi et al,53 UE injury: subclavian, EEA, venous interposition PO IV heparin 5–7 d and
2006 axillary, brachial, graft, ligation discharged on oral aspirin
radial, ulnar artery 100 mg tablet/d for 12 wk
Ergünes et al,12 Brachial artery injury Primary repair, SVIG Systemic and intraoperative
2006 heparin (with PO systemic
heparin patients with
graft and soft tissue injury
Carrafiello et al,54 UE injury: subclavian, Bare stent, percutaenous PO 0.7 IU of LMW heparin
2011 axillary, brachial transluminal angioplasty, bid for 30 d with lifelong
artery stent graft 120 mg/d ticlopidine or
acetylsalicylic acid
Temming et al,55 Ulnar artery thrombosis Descending branch of the Aspirin 100 mg for 2 wk
2011 hypothenar hammer lateral circumflex femoral
syndrome artery graft
Krishnan et al,56 Upper and lower SVIG, Dextran-40 for first 24 h
2014 extremity arterial polytetrafluoroethylene followed by
injury subcutaneous LMW
heparin for a week.
Discharged on 6-wk
aspirin (150 mg daily)
Ivatury et al,9 Penetrating extremity Primary, EEA, autogenous Intraoperative systemic
2014 arterial Injury graft, prosthetic Graft heparin and local heparin

Abbreviations: bid, 2 times a day; EEA, end-to-end anastamosis; d, day; h, hour; IO, intraoperative; IV, intravenous; LMW,
low molecular weight; PO, postoperative; SVIG, saphenous vein interposition graft; tid, 3 times a day; UE, upper extrem-
ity; wk, week.

and a heparin bolus (50–100 U/kg) before releasing
the clamps. For replants, they also recommended
dextran-40 at 0.4 mL/kg/h, which was weaned off
by postoperative day 5.58 Given the similarity in
arterial repair, their protocol could potentially be
extrapolated to upper extremity arterial injuries.
Overall, anticoagulation use is prevalent in the
management of upper extremity arterial injuries
to prevent thrombosis and protect the patency of
repair. Although these agents have theoretic use,
well-supported clinical evidence is needed to
formulate standardized guidelines.
TREATMENT OUTCOME
Upper extremity arterial injuries may present
alone or with a magnitude of associated
injuries. Although various factors contribute to
94 Lebowitz & Matzon
the outcome, the presence of an associated
neurologic injury is associated with long-term
morbidity. Patients with an associated nerve injury
have a 27% to 44% rate of functional disability.9,12
To minimize this risk, it is recommended that nerve
injuries be repaired as early as possible.3 Apart
from recognizing an associated neurologic injury,
early detection of graft failure, compartment syn-
drome, and infection also dramatically improve
patient outcome.7
Upper extremity arterial injuries can present in
myriad ways. Managing these injuries likely re-
quires the assistance of multiple medical teams,
with a goal to first preserve life and then limb.
Overall, with the adjunct of thorough diagnostic
tools, increased availability of resources, and an
aggressive philosophy of surgical intervention,
limb salvage rates are high (92% to 100%) and
mortality rates are low (0% to 24%).4
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